Medicine

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Most, if not all, of us, if asked to be cared for by a television doctor if we had a serious medical problem, would select Dr. Gregory House of the TV series House. He would fail most of the core competencies except for knowledge and skill.

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At the peak of the crisis, the hospital had the equivalent of eight full-time pharmacy employees battling the shortage. Technicians worked through the night to mix saline by hand, while nurses injected the solution of salt in water into patients using syringes — a task normally done by the metal stands and plastic bags used for intravenous drips. “Sometimes we’ve had over 20 nurses at a time doing that,” ..

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I love statistics, but I am just not very good at it, and find much of it extremely counter intuitive (which is why it is ‘fun’). The Monty Hall problem floored me, but then Paul Erdos got it wrong too (I am told), so I am in good — and numerate — company. During my intercalated degree in addition to a research methods tutorials (class size, n=2), we had one three hour stats practical each week (class size, n=10). We each used a Texas calculator, and working out a SD demanded concentration. Never mind, that during the rest of the week we were learning how to use FORTRAN and SPSS on a mainframe, ‘slowing’ down the process was useful.

Medicine has big problems with statistics although it is often not so much to do with ‘mathematical’ statistics but evidence in a broader sense. IMHO the biggest abusers are the epidemiologists and the EBM merchants with their clickbait NNT and the like. But I do think this whole field deserves much greater attention in undergraduate education, and cannot help but feel that you need much more small group teaching over a considerable period of time. Otherwise, it just degenerates into ‘What is this test for?’ exam fodder style of learning.

The problems we have within both medicine and medical research have been talked about for a long while. Perhaps things are improving, but it is only more recently that this topic has been acknowledged as a problem amongst practising scientists (rather than medics). This topic certainly resurfaces with increased frequency, and there have been letters on it in Nature recently. I like this one:

Too many practitioners who discuss the misuse of statistics in science propose technical remedies to a problem that is essentially social, cultural and ethical (see J. Leek et al. Nature 551, 557–559; 2017). In our view, technical fixes are doomed. As Steven Goodman writes in the article, there is nothing technically wrong with P values. But even when they are correct and appropriate, they can be misunderstood, misrepresented and misused — often in the haste to serve publication and career. P values should instead serve as a check on the quality of evidence.

I think you could argue with the final sentence of this (selected) quote, but they are right about the big picture: narrow technical solutions are not the problem here. Instead, we are looking at a predictable outcome of the corruption of what being a scientist means.

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The Osborne effect is a term referring to the unintended consequences of a company announcing a future product, unaware of the risks involved or when the timing is misjudged, which ends up having a negative impact on the sales of the current product. This is often the case when a product is announced too long before its actual availability. This has the immediate effect of customers canceling or deferring orders for the current product, knowing that it will soon be obsolete, and any unexpected delays often means the new product comes to be perceived as vaporware, damaging the company’s credibility and profitability.

AI and associated technologies will have major effects in some areas of medicine. Think skin cancer diagnosis, for certain; or this weekend story in the FT on eye disease; and radiology and pathology. This then begs the question, whether these skills are so central to expertise within a clinical domain, that students should think hard about these areas as a career. Of course, diagnosis of skin lesions is not all a clinical expert in this domain does. Ditto, ophthalmologists do more than look at retinas. Automated ECG readers have not put cardiologists out of work, after all. And many technical advances increase — not reduce — workloads.

But at some stage, people might want to start wondering if some areas of medicine are (not) going to be secure as long term careers. The Osborne metaphor should be a warning about how messy all this could be. Hype, has costs.

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After earning his medical degree in 1951 he trained in hospitals in Montreal. “To my surprise I also found I enjoyed clinical medicine,” he wrote in his Nobel prize biography. Then he quipped, “It took three years of hospital training after graduation, a year of internship and two of residency in neurology, before that interest finally wore off.”

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This article in the NEJM gets to the kernel of one of the major problems in medicine: the increasing dysfunction of doctor-patient interaction fuelled — in part — by awful IT, and a systematic ability to admit that it is no longer possible to actually do what is required within the ‘allocated’ time. In many industries the goal is to match task with skill and, wherever possible, to reduce costs by allocating low skill tasks to those who cost less: ‘right person at the right time’. There is a variation of this in medicine: those charged with ‘support’ or undertaking ‘low skill tasks’ have just been removed, meaning all tasks — both high and low — are done by the same practitioner, but without any change in time allocated. This is akin to asking the pilot of a plane to serve you snacks and check you in, but keep the schedules the same.

In terms of medicine, that this happens is not so much a manifestation of a managerial view that places little value on ‘care’ (true), nor where business innovation (sic) is viewed as synonymous with sacking people (true), but a complete failure to understand their own business and what their own product is. In an ideal world businesses like this should go bust. The problems are when: they are run by the government; there are third party payers; or there is actively created informational asymmetry. Sometimes all three apply.

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‘On December 16, 2017, the staff of the Centers for Disease Control and Prevention (CDC) were instructed not to use 7 words in its 2019 budget appropriation request: diversity, transgender, vulnerable, fetus, entitlement, evidence-based, and science-based. These basic phrases are intrinsic to public health. The US Department of Health and Human Services (HHS) offered alternative word choices, such as by modifying “evidence-based” with “community standards and wishes” and using “unborn child” instead of “fetus.”’

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In the history of science and technology, the engineering artefacts have almost always preceded the theoretical understanding: the lens and the telescope preceded optics theory, the steam engine preceded thermodynamics, the airplane preceded flight aerodynamics, radio and data communication preceded information theory, the computer preceded computer science.

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Recent years have seen a major drive by government, the NHS, and mental health charities to change attitudes towards mental health and to raise its profile in line with physical health. In a crescendo of media coverage, royals and celebrities have opened up about their own struggles.

Despite having welcomed Prince Harry’s interview about his mental health in April, Wessely believes we can have too much of a good thing: too much awareness. He particularly questions surveys in which most students report mental health problems. “We should stop the awareness now. In fact, if anything we might be getting too aware. One wonders what’s happening when you have 78% of students telling their union they have mental health problems-you have to think, ‘Well, this seems unlikely.'”

Simon Wessely quoted in the BMJ 23 September 2017 p433

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Enrico Fermi was big on back-of-the-envelope calculations. I cannot match his brain, but I like playing with simple arithmetic. Here are some notes I made several years ago after reading a paper from Mistry et al in the British Journal of Cancer on cancer incidence projections for the UK.

For melanoma we will see a doubling between now (then) and 2030, half of this is increase in age specific incidence and half due to age change. Numbers of cases for the UK:

1984: 3,000 cases

2007: 11,000

2030: 22,000

If we assume we see 15 non-melanomas (mimics) for every melanoma, the number of OP visits with or without surgery is as follows.

1984: 45,000 cases

2007: 165,000 cases

2030: 330,000 cases

This is for melanoma. The exponent for non-melanoma skin cancer is higher, so these numbers are an underestimate of the challenge we face. Once you add in ‘awareness campaigns’, things look even worse.

At present perhaps 25% of consultant dermatology posts are empty (no applicants), and training numbers and future staffing allowing for working patterns, reducing. Waiting times to see a dermatologist in parts of Wales are over a year. The only formal training many receive in dermatology as an undergraduate can be measured in days. Things are worse than at any time in my career. It is with relief, that I say I am married to a dermatologist.

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The growth of medical tourism in Poland has been mirrored in other central European countries. Hungary also has a reputation for specialising in dental services for foreigners, while Czech Republic has developed a market in cataract surgery. Poland is well known for its plastic surgeons as well as dentists.

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The concept of continuity of care is important and with winter approaching rapidly in the UK, clinicians should lead the way in ensuring patients are looked after by the right specialist team, in the right place first time and avoid the ‘martini’ principle of hospital care – any time, any bed, anywhere. If we can reduce the number of boarded or outlying patients we will improve their care and also reduce overcrowding in the hospitals.

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I like computers (see previous post), but despair of them in the clinical context of keeping medical records. By contrast nobody sane doubts that computers are advantageous in other medical contexts: imaging, radiotherapy, or even using an insulin pump. We don’t have problems with the latter instances, because self-evidently computers work, and they are the result of a culture of improvement. Not so with electronic medical records, where a neutral observer might thing that the purpose is to save money in one budget at the expense of diminishing clinical care in another. The economists might talk about externalities, but essentially many electronic record keeping systems are a form of pollution of the clinical workspace.

The following quote caught my eye because, whilst in Scandinavia recently, a dermatologist from Denmark was expressing frustration with how bad their computer systems are; and how older physicians choose to ignore them by retiring early. I heard a similar tale from the US in the summer, from a dermatologist who takes a financial hit because he has not implemented electronic records. He says he can either manage patients or do IT (and yes, he is planning to get out early).

Electronic medical records (EMRs) have resulted in increased documentation burden, with physicians spending up to 2 hours on EMR-related tasks for every 1 patient-care hour. Although EMRs offer care delivery integration, they have decreased physician job satisfaction and increased physician burnout across multiple fields, including dermatology.

I would add, that I have read that the average ER doc on a shift in the US presses his mouse 4000 times.

A long time ago, Richard Doll wrote an article pointing out that hospital record systems such as hospital activity analysis were perhaps useful to managers, but not much use for doctors or researchers. He was right, and I even published a paper saying similar things. My experience of electronic records in hospitals is that they are designed for the purpose of ‘management’ not clinical care. Contrary to what many say, these two activities have little in common, and share few goals. Our care system is not designed for care or caring, and our software is not designed for clinicians or patients. As for EMR, we are still waiting for our VisiCalc or Photoshop. If somebody can pull it off, it would be worth a Nobel.

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Allergan has been particularly aggressive in trying to skirt the IPR system. In September, it took the unprecedented step of transferring patents protecting its prescription eyedrop, Restasis, to the Saint Regis Mohawks. The tribe — which received a $13.5m fee and up to $15m in annual royalties — then claimed it had sovereign immunity from intellectual property challenges launched through IPR.

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Marriage, however, proved to be a towering practical problem — Princeton, where Feynman was now pursuing a Ph.D., threatened to withdraw the fellowships funding his graduate studies if he were to wed, for the university considered the emotional and pragmatic responsibilities of marriage a grave threat to academic discipline. [Here]

The above is about Richard Feynman, but reminds me of a story closer to home, told to me by a consultant dermatologist (who I will call CS) and former academic. CS, then a senior registrar, on entering the departmental library, was pleased to see the elderly professor reaching for books on the top shelf. CS, with evident pride, told the professor that he had good news: he was engaged to be married. The professor replied: ‘Sorry to hear that CS, I had high hopes for you’.

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The first is reasonable, but not grounded in reality. As AJP Taylor once said: 90% right and 100% wrong. It is what happens when all the context of a thesis has been stripped away. The second is both more grounded in reality and philosophically sound.

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Speaking at the Royal College of GPs’ annual conference in Liverpool on Thursday, he said: “The old model of 10-minute appointments doesn’t really work for patients with multiple long-term conditions who may need 30, 40, 50 minutes to get to the bottom of all their needs.”

Awhile back, I read that a Danish primary care doc had been prosecuted because he had made key decisions about a patient based on a 10 minute consultation. In one sense I was cheered by this. But talking to Danish dermatologists last week, I am not so sanguine. It seems that yet more new ‘efficient’ IT is the weapon to degrade the consultation even further. Eventually there really will be no time to let the patient into the consultation room. And still the mantra of consultations skills for medical students will continue. All irony intended.

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Physicians have always been busy people, although they have generally controlled the way they use their time. In 1993, for example, family practitioners were seeing, on average, one patient every 20 minutes; general internists were seeing one every 26 minutes 1. These visit times were not long but perhaps were not unreasonable, particularly considering that they represented a mix of new and follow-up visits and that “fast” and “slow” British general practitioners had mean visit lengths of 7 and 9 minutes, respectively 2. Recently, however, the invisible hand of the marketplace has squeezed appointment schedules in an ever-tightening grip: In late 1995, 41% of physicians in an important U.S. survey reported that the amount of time they spent with their patients had decreased during the previous 3 years 3. This erosion of encounter time has taken its toll on physicians 1, 3. Moreover, it is equally distressing to patients because patients value their physicians’ “information giving” highly 4 and, as Howard Waitzkin has sensibly pointed out, “Information giving takes time. We cannot expect it to go well if we are too busy” 5. It does not take a rocket scientist (in the current parlance) to understand why both patients and their physicians have become increasingly dissatisfied as visit lengths have grown shorter 2, 6.

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This is from an article discussing the difficulties in recommending people to content they might like. The bigger picture is the dismal state of online journalism / news and polluters not paying. But Netflix’s understanding about how fine scale a taxonomy has to be, struck a chord with me. This is exactly the problem of diagnosis in some areas of medicine.

The latter is my favorite. Four years ago, I realized the size and scope of Netflix’s secret weapon, its suggestion system, when reading this seminal Alex Madrigal piece in The Atlantic. Madrigal was first in revealing the number of genres, sub-genres, micro-genres used by Netflix’s descriptors for its film library: 76,897! This entails the incredible task of manually tagging every movie and generating a vast set of metadata ranging from “forbidden-love dramas” to heroes with a prominent mustache.

This reminds me of the old story about how impressed somebody was, after being shown some small computing device that could ‘think’ using powerful algorithms. The observer did however ask about the aircraft hanger size machine that came with it: that was necessary to implement all the code for the exceptions to this universal reasoning machine, he was told.

Lots of room too, for fake news and fake diagnoses.

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This was a quote from an article by an ex-lawyer who got into tech and writing about tech. Now some of by best friends are lawyers, but this chimed with something I came across by Benedict Evans on ‘why you must pay sales people commissions’. The article is here (the video no longer plays for me).

The opening quote poses a question:

I felt a little odd writing that title [ why you must pay sales people commissions]. It’s a little like asking “Why should you give engineers big monitors?” If you have to ask the question, then you probably won’t understand the answer. The short answer is: don’t, if you don’t want good engineers to work for you; and if they still do, they’ll be less productive. The same is true for sales people and commissions.

The argument is as follows:

Imagine that you are a great sales person who knows you can sell $10M worth of product in a year. Company A pays commissions and, if you do what you know you can do, you will earn $1M/year. Company B refuses to pay commissions for “cultural reasons” and offers $200K/year. Which job would you take? Now imagine that you are a horrible sales person who would be lucky to sell anything and will get fired in a performance-based commission culture, but may survive in a low-pressure, non-commission culture. Which job would you take?

But the key message for me is:

Speaking of culture, why should the sales culture be different from the engineering culture? To understand that, ask yourself the following: Do your engineers like programming? Might they even do a little programming on the side sometimes for fun? Great. I guarantee your sales people never sell enterprise software for fun. [emphasis mine].

Now why does all this matter? Well personally, it still matters a bit, but it matters less and less. I am towards the end of my career, and for the most part I have loved what I have done. Sure, the NHS is increasingly a nightmare place to work, but it has been in decline most of my life: I would not recommend it unreservedly to anybody. But I have loved my work in a university. Research was so much fun for so long, and the ability to think about how we teach and how we should teach still gives me enormous pleasure: it is, to use the cliche, still what I think about in the shower. The very idea of work-life balance was — when I was young and middle-aged at least — anathema. I viewed my job as a creative one, and building things and making things brought great pleasure. This did not mean that you had to work all the hours God made, although I often did. But it did mean that work brought so much pleasure that the boundary between my inner life and what I got paid to do was more apparent to others than to me. And in large part that is still true.

Now in one sense, this whole question matters less and less to me personally. In the clinical area, many if not most clinicians I know now feel that they resemble those on commission more than the engineers. Only they don’t get commission. Most of my med school year who became GPs will have bailed out. And I do not envy the working lives of those who follow me in many other medical specialties in hospital. Similarly, universities were once full of academics who you almost didn’t need to pay, such was their love for the job. But modern universities have become more closed and centrally managed, and less tolerant of independence of mind.

In one sense, this might go with the turf — I was 60 last week. Some introspection, perhaps. But I think there really is more going on. I think we will see more and more people bailing out as early as possible (no personal plans, here), and we will need to think and plan for the fact that many of our students will bail out of the front line of medical practice earlier than we are used to. I think you see the early stirrings of this all over: people want to work less than full-time; people limit their NHS work vis a vis private work; some seek administrative roles in order to minimise their face-to-face practice; and even young medics soon after graduation are looking for portfolio careers. And we need to think about how to educate our graduates for this: our obligations are to our students first and foremost.

I do not think any of these responses are necessarily bad. But working primarily in higher education, has one advantage: there are lost of different institutions, and whilst in the UK there is a large degree of groupthink, there is still some diversity of approach. And if you are smart and you fall outwith the clinical guilds / extortion rackets, there is no reason to stay in the UK. For medics, recent graduates, need to think more strategically. The central dilemma is that depending on your specialty, your only choice might appear to be to work for a monopolist, one which seeks to control not so much the patients cradle-to-grave, but those staff who fall under its spell, cradle-to-grave. But there are those making other choices — just not enough, so far.

An aside. Of course, even those who have achieved the most in research do not alway want to work for nothing, post retirement. I heard the following account first hand from one of Fred Sanger’s previous post-docs. The onetime post-doc was now a senior Professor, charged with opening and celebrating a new research institution. Sanger — a double Laureate — would be a great catch as a speaker. All seemed will until the man who personally created much of modern biology realised the date chosen was a couple of days after he was due to retire from the LMB. He could not oblige: the [garden] roses need me more!

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To some extent, many UK governments have trialled their plans for much of medicine on dentists and dentistry. To some extent, fear of what the ballot box may say, has limited their wishes. But here is a well written piece about dentists and dentistry that should be read by many medics, both as a warning, and a guide to action. Dermatology and dentistry share many genes.

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There is perhaps too much Machine learning/AI hype in this article — or at least for my taste, but it is well worth a read. The problem the authors are grappling with is perhaps the central intellectual problem modern medicine faces: how formal can our methods become? And how can we use a variety of cognitive prostheses to guide clinical behaviour.

Asking doctors to work harder or get smarter won’t help. Calls to reduce “unnecessary” care fall flat: we all know how difficult it’s become to identify what care is necessary. Changing incentives is an appealing lever for policymakers, but that alone will not make decisions any easier: we can reward physicians for delivering less care, but the end result may simply be less care, not better care.

Informatics — using the term in the broadest possible sense — and the management of expertise, is the central challenge facing medicine and medical care. It is where the action should be. The authors are right about this, but their caution is also true: “The state of our health care system offers little reason for optimism.” Amen. And spare me ‘realistic medicine’.

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No, I could not run, lead or guide a pharma company. Tough business. But I just hope their executives do not really believe most of what they say. So, in a FT article about the new CE of Novartis, Vas Narasimhan, has vowed to slash drug development costs; there will be a productivity revolution; 10-25 per cent could be cut from the cost of trials if digital technology were used to carry them out more efficiently.

I really think of our future as a medicines and data science company, centred on innovation and access (read that again, parenthesis mine)

And to add insult to injury:

Dr Narasimhan cites one inspiration as a visit to Disney World with his young children where he saw how efficiently people were moved around the park, constantly monitored by “an army of Massachusetts Institute of Technology-trained data scientists”.

And not that I am a lover of Excel…

No longer rely on Excel spreadsheets and PowerPoint slides, but instead “bring up a screen that has a predictive algorithm that in real time is recalculating what is the likelihood our trials enrol, what is the quality of our clinical trials”

Just recall that in 2000 it would have been genes / genetics / genomics rather than data / analytics / AI / ML etc

So, looks to me like lots of cost cutting and optimisation. No place for a James Black, then.

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For some companies, that can mean specifically focusing on young people, as Ahmet Bozer, president of Coca-Cola International, described to investors in 2014. “Half the world’s population has not had a Coke in the last 30 days,” he said. “There’s 600 million teenagers who have not had a Coke in the last week. So the opportunity for that is huge.”

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“Physical exam skills are eroding fairly significantly. We see that year after year. The masters who taught us are gone, and we’re not teaching the people below us well enough, for all the reasons we talked about.

At the same time, we grossly overestimated the average clinician’s ability to do an extremely good physical exam and to make all of the relevant physical findings. It has been documented over and over again that the average person’s ability to use a stethoscope and document a murmur accurately is a coin flip. The ability of the average house officer to do volume assessment based on a physical exam is terribly low.”

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Many many years ago I wrote a few papers about — amongst other things — the statistical naivety of the EBM gang. I enjoyed writing them but I doubt they changed things very much. EBM as Bruce Charlton pointed out many years ago has many of the characteristic of a cult (or was it a Zombie? — you cannot kill it because it is already dead). Anyway one of the reasons I disliked a lot of EBM advocates was because I think they do not understand what RCTs are, and of course they are often indifferent to science. Now, in one sense, these two topics are not linked. Science is meant to be about producing broad ranging theories that both predict how the world works and explain what goes on. Sure, there may be lots of detail on the way, but that is why our understanding of DNA and genetics today is so different from that of 30 years ago.

By contrast RCTs are usually a form of A/B testing. Vital, in many instances, but an activity that is often a terminal side road rather than a crossroads on the path to understanding how the world works. That is not to say they are not important, nor worthy of serious intellectual endeavour. But the latter activity is for those who are capable of thinking hard about statistics and design. Instead the current academic space makes running or enrolling people in RCT some sort of intellectual activity : it isn’t, rather it is a part of professional practice, just as seeing patients is. Companies used to do it all themselves many decades ago, and they didn’t expect to get financial rewards from the RAE/REF for this sort of thing. There are optimal ways to stack shelves that maths geeks get excited about, but those who do the stacking do not share in the kudos — as in the cudos [1] — of discovery.

Harrell is the author of one of those classic books…. . But I think the post speaks to something basic. RCT are not facsimiles of clinical practice, but some sort of bioassay to guide what might go on in the clinic. Metaphors if you will, but acts of persuasion not brittle mandates. This all leaves aside worthy debates on the corruption that has overtaken many areas of clinical measurement, but others can speak better to that than me.

[1] I really couldn’t resist.

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So, it is reported that the UK has the best health system in the developed world (according to the Commonwealth Fund). But when you read a little more, the UK comes third (of 11) on access, and 10th (of 11) on healthcare outcomes (mortality and morbidity). The UK also has the second highest rate of deaths amenable to healthcare after the US (Switzerland is lowest). The latter is no surprise if you know anything about Swiss healthcare or hospitals across Europe. Their doctors don’t look so scruffy as the UK ones, either. I guess you can make your composite measures in many ways, but I know what I would choose. (22 July 2017, BMJ 2017;358:j3442)

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My mother in law has two ‘Italian’ cats. One has worms, the other apparently not. Medication time. The diseased cat refuses the medication, whatever enticements are on offer. The undiseased (or cat at ease) scoffs not only his own medication, but that of his partner.

There are plenty of cats in South Wales, and I doubt that coal dust kills off the worms. Julian (Tudor-Hart), where did the idea come from? [ Yes, before you write in, not quite the inverse care as JTH meant it, but metaphors are the viruses of novelty, so who knows.]

reestheskin.me

reestheskin.me is mainly about education and medicine, and how these domains intersect. I think Roger Schank has it spot on when he says: ‘There are only two things wrong with the education system (i) what we teach and (ii) how we teach it'.